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Guidelines

A summary of the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA, 2013) and the European Society of Cardiology (ESC, 2012) policies on pharmaco-invasive therapy for the treatment of STEMI patients is given in the table below.

The ESC guideline committee states,

“The benefits of early routine PCI after thrombolysis were seen in the absence of increased risk of adverse events…Thus, early referral for angiography with subsequent PCI (if indicated) should be the standard of care after thrombolysis…”1

Furthermore, based on current data, a time window of 3 to 24 hours after successful lysis is recommended before the start of PCI.1

Access the full ESC guidelines for more details about recommendations on pharmaco-invasive therapy.

If fibrinolysis is given and is successful, the ACCF/AHA guideline committee concludes it is reasonable to transfer to a PCI-capable facility for coronary angiography, ideally within 24 hours of fibrinolysis, but no sooner than 2 to 3 hours after the administration of fibrinolytic therapy [Class IIa, Level B].2

  • “In the absence of contraindications, fibrinolytic therapy should be given to patients with STEMI and onset of ischaemic symptoms within the previous 12 hours when it is anticipated that primary PCI cannot be performed within 120 minutes of [first medical contact].” [Class I, Level A]2
  • Moreover, in stable patients post fibrinolysis, both coronary angiography and PCI “can be performed as soon as logistically feasible at the receiving hospital, and ideally within 24 hours, but should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.” [Class IIa, Level B]2
  • Access the full ACCF/AHA guidelines for more details about recommendations on pharmaco-invasive therapy.

Recently, Dalal et al. developed a “Consensus Statement for Early Reperfusion and Pharmaco-Invasive Approach in Patients Presenting with Chest Pain Diagnosed as STEMI (ST-elevation myocardial infarction) in an India Setting” in collaboration with STEMI India and the review and comments of 150 experts representing 16 states in India.3

Based on the results from STREAM, among other trials, and registry data, the authors put together a STEMI management scheme to aid health care professionals in India in the decision-making and treatment processes for patients presenting with acute myocardial infarction. In their recommendation, Dalal et al. recognise that PPCI is the gold-standard, however, based on a “time-guided ‘Protocol/Plan of Action’”, they suggest a pharmaco-invasive approach, defined as “early fibrinolysis followed by PCI 3-24 hours later”, be implemented.3

Read the detailed consensus report.

References: 

  1. Steg PG et al., The Task Force on the Management of ST-Segment Elevation Acute Myocardial Infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J 2012;33:2569-2619.

  2. O’Gara P et al. 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology Foundation and the American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2013;61:e78-e140.

  3. Dalal JJ et al. 2013 Consensus Statement for Early Reperfusion and Pharmaco-invasive Approach in Patients Presenting with Chest Pain Diagnosed as STEMI (ST Elevation Myocardial Infarction) in an Indian Setting. JAPI 2014;62:473-483.